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Objective The aim of the present study was to provide a summary of a systematic review of literature reporting benefits and limitations of implementing National Emergency Access Target (NEAT), a target stipulating that a certain proportion of patients presenting to hospital emergency departments are admitted or discharged within 4h of presentation. Methods A systematic review of published literature using specific search terms, snowballing techniques applied to retrieved references and Google searches was performed. Results are presented as a narrative synthesis given the heterogeneity of included studies. Results Benefits of a time-based target for emergency care are improved timeliness of emergency care and reduced in-hospital mortality for emergency admissions to hospital. Limitations centre on using a process measure (time) alone devoid of any monitoring of patient outcomes, the threshold nature of a time target and the fact that currently NEAT combines the measurement of clinical management of two very different patient cohorts seeking emergency care: less acute patients discharged home and more acute patients admitted to hospital. Conclusions Time-based access targets for emergency presentations are associated with significant improvements in in-hospital mortality for emergency admissions. However, other patient-important outcomes are deserving of attention, choice of targets needs to be validated by empirical evidence of patient benefit and single targets need to be partitioned into separate targets pertaining to admitted and discharged patients. What is known about the topic? Time targets for emergency care originated in the UK. The introduction of NEAT in Australia has been controversial. NEAT directs that a certain proportion of patients will be admitted or discharged from an emergency department (ED) within 4h. Recent dissolution of the Australian National Partnership Agreement (which provided hospitals with financial incentives for achieving NEAT compliance) has prompted a re-examination of the 4-h rule, the evidence underpinning its introduction and its benefits and risks to patients What does this paper add? This paper is executive summary of key findings from a systematic literature review on the benefits and limitations of NEAT (the 4-h rule) commissioned by the Queensland Clinical Senate to inform future policy and targets. What are the implications for practitioners? There is evidence that a time-based target has been associated with a reduction in in-hospital mortality for emergency admissions to Australian hospitals. Concerns remain regarding a time-based target alone being used to drive redesign efforts at improving access to emergency care. A time-based target should be coupled with close monitoring of patient outcomes of emergency care. Target thresholds need to be evidence based and separate targets should be reported for admitted, discharged and all patients presenting to the ED.

Objective: We explored the relationship between the National Emergency Access Target (NEAT) compliance rate, defined as the proportion of patients admitted or discharged from emergency departments (EDs) within 4 hours of presentation, and the risk-adjusted in-hospital mortality of patients admitted to hospital acutely from EDs., Design, Setting and Participants: Retrospective observational study of all de-identified episodes of care involving patients who presented acutely to the EDs of 59 Australian hospitals between 1 July 2010 and 30 June 2014., Main Outcome Measure: The relationship between the risk-adjusted mortality of inpatients admitted acutely from EDs (the emergency hospital standardised mortality ratio [eHSMR]: the ratio of the numbers of observed to expected deaths) and NEAT compliance rates for all presenting patients (total NEAT) and admitted patients (admitted NEAT)., Results: ED and inpatient data were aggregated for 12.5 million ED episodes of care and 11.6 million inpatient episodes of care. A highly significant (P < 0.001) linear, inverse relationship between eHSMR and each of total and admitted NEAT compliance rates was found; eHSMR declined to a nadir of 73 as total and admitted NEAT compliance rates rose to about 83% and 65% respectively. Sensitivity analyses found no confounding by the inclusion of palliative care and/or short-stay patients., Conclusion: As NEAT compliance rates increased, in-hospital mortality of emergency admissions declined, although this direct inverse relationship is lost once total and admitted NEAT compliance rates exceed certain levels. This inverse association between NEAT compliance rates and in-hospital mortality should be considered when formulating targets for access to emergency care.

Objective The aim of the present study was to identify patient and non-patient factors associated with reduced mortality among patients admitted from the emergency department (ED) to in-patient wards in a major tertiary hospital that had previously reported a near halving in mortality in association with a doubling in National Emergency Access Target (NEAT) compliance over a 2-year period from 2012 to 2014. Methods We retrospectively analysed routinely collected data from the Emergency Department Information System (EDIS) and hospital discharge abstracts on all emergency admissions during calendar years 2011 (pre-NEAT interventions) and 2013 (post-NEAT interventions). Patients admitted to short-stay wards and then discharged home, as well as patients dying in the ED, were excluded. Patients included in the study were categorised according to age, time and day of arrival to the ED, mode of transport to the ED, emergency triage category, type of clinical presentation and major diagnostic codes. Results The in-patient mortality rate for emergency admissions decreased from 1.9% (320/17022) in 2011 to 1.2% (202/17162) in 2013 (P<0.001). There was no change from 2011 to 2013 in the percentage of deaths in the ED (0.19% vs 0.17%) or those coded as in-patient palliative care (17.9% vs 22.2%). Although deaths were not associated with age by itself, the mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7% (P=0.011). A higher mortality rate was seen among patients presenting to ED triage between midnight and 12 noon than at other times in 2011 (2.5% vs 1.5%; P<0.001), but this difference disappeared by 2013 (1.3% vs 1.1%; P=0.150). A similar pattern was seen among patients presenting on weekends versus weekdays: 2.2% versus 1.7% (P=0.038) in 2011 and 1.3% versus 1.1% (P=0.150) in 2013. Fewer deaths were noted among patients with acute cardiovascular or respiratory disease in 2013 than in 2011 (1.7% vs 3.6% and 1.5% vs 3.4%, respectively; P<0.001 for both comparisons). Mode of transport to the ED or triage category was not associated with changes in mortality. These analyses took account of any possible confounding resulting from differences over time in emergency admission rates. Conclusions Improved NEAT compliance as a result of clinical redesign is associated with improved in-patient mortality among particular subgroups of emergency admissions, namely older patients with complex medical conditions, those presenting after hours and on weekends and those presenting with time-sensitive acute cardiorespiratory conditions. What is known about the topic? Clinical redesign aimed at improving compliance with NEAT and reducing time spent within the ED of acutely admitted patients has been associated with reduced mortality. To date, no study has attempted to identify subgroups of patients who potentially derive the greatest benefit from improved NEAT compliance in terms of reduced risk of in-patient death. It also remains unclear as to what extent non-patient factors (e.g. admission practices and differences in coding of palliative care patients) affect or confound this reduced risk. What does this paper add? The present study is the first to reveal that enhanced NEAT compliance is associated with lower mortality among particular subgroups of emergency patients admitted to in-patient wards. These include older patients with complex medical conditions, those presenting after hours or on weekends or those with time-sensitive acute cardiorespiratory conditions. These results took account of any possible confounding resulting from differences over time in emergency admission rates, deaths in the ED, numbers of short-stay ward admissions and coding of palliative care deaths. What are the implications for practitioners? Efforts aimed at improving NEAT compliance and efficiencies at the ED-in-patient interface appear to be worthwhile in reducing in-patient mortality among particular subgroups of emergency admissions at high risk. More research is urgently needed in identifying patient- and system-level factors that predispose to higher mortality rates in such populations, but are potentially amenable to focused interventions aimed at optimising transitions of care at the ED-in-patient interface and increasing NEAT compliance for patients admitted to in-patient wards from the ED.

Background: Movement of emergency patients across the emergency department (ED)-inpatient ward interface influences compliance with National Emergency Access Targets (NEAT). Uncertainty exists as to how best measure patient flow, NEAT compliance and patient mortality across this interface., Objective: To compare the association of NEAT with new and traditional markers of patient flow across the ED-inpatient interface and to investigate new markers of mortality and NEAT compliance across this interface., Methods: Retrospective study of consecutive emergency admissions to a tertiary hospital (January 2012 to June 2014) using routinely collected hospital data. The practical access number for emergency (PANE) and inpatient cubicles in emergency (ICE) are new measures reflecting boarding of inpatients in ED; traditional markers were hospital bed occupancy and ED attendance numbers. The Hospital Standardised Mortality Ratio (HSMR) for patients admitted via ED (eHSMR) was correlated with inpatientNEAT compliance rates. Linear regression analyses assessed for statistically significant associations (expressed as Pearson R coefficient) between all measures and inpatient NEAT compliance rates., Results: PANE and ICE were inversely related to inpatient NEAT compliance rates (r = 0.698 and 0.734 respectively, P < 0.003 for both); no significant relation was seen with traditional patient flow markers. Inpatient NEAT compliance rates were inversely related to both eHSMR (r = 0.914, P = 0.0006) and all-patient HSMR (r = 0.943, P = 0.0001)., Conclusions: Traditional markers of patient flow do not correlate with inpatient NEAT compliance in contrast to two new markers of inpatient boarding in ED (PANE and ICE). Standardised mortality rates for both emergency and all patients show a strong inverse relation with inpatient NEAT compliance.

Objective: To implement and evaluate strategies for improving access to emergency department (ED) care in a tertiary hospital., Methods: A retrospective pre-post intervention study using routinely collected data involving all patients presenting acutely to the ED of a major tertiary hospital over a 2-year period. Main outcome measures were changes in: the percentage of patients exiting the ED (all patients, patients discharged directly from the ED, patients admitted to inpatient wards); mean patient transit times in the ED; inpatient mortality rates; rates of ED 'did not wait' and re-presentations within 48 h of ED discharge; and selected safety indicators. Qualitative data on staff perceptions of interventions were also gathered., Results: Working groups focused on ED internal processes, ED-inpatient unit interface, hospital-wide discharge processes and performance monitoring and feedback. Twenty-five different reforms were enacted over a 9-month period from April to December 2012. Comparing the baseline period (January-March 2012) with the post-reform period (January-March 2013), the percentage of patients exiting the ED within 4 h rose for all patients presenting to the ED (from 32% to 62%), for patients discharged directly from the ED (from 41% to 75%) and for admitted patients (from 12% to 32%; P<0.001 for all comparisons). The mean (±s.d.) time all patients spent in the ED was reduced from 7.2±5.8 to 4.4±3.5 h (P<0.001) and, for admitted patients, was associated with reduced in-hospital mortality (from 2.3% to 1.7%; P=0.045). The 'did not wait' rates in ED fell from 6.9% to 1.9% (P<0.001), whereas ED re-presentations within 48 h among patients discharged from the ED rose slightly (from 3.1% to 3.8%; P=0.023). Improvements in outcome measures were maintained over the subsequent 12 months., Conclusions: Multiple reforms targeting processes both within the ED and its interface with inpatient units greatly improved access to ED care over 12 months and were associated with decreased in-hospital mortality. WHAT IS KNOWN ABOUT THIS TOPIC?: Prolonged stays in the ED result in overcrowding, delayed ambulance access to ED care and increased adverse outcomes for admitted patients. The introduction in Australia of National Emergency Access Targets (NEAT), which stipulate at least 70% of patients in the ED must exit the department within 4h, have spurred hospitals into implementing a wide range of reforms with varying levels of success in achieving such targets. WHAT DOES THIS PAPER ADD?: This study demonstrates how multiple reforms implemented in a poor performing tertiary hospital caused the proportion of patients exiting the ED within 4h to double within 9 months to reach levels comparable with best performing peer hospitals. This was associated with a 26% reduction in in-hospital mortality for admitted patients and no clinically significant adverse effects. It demonstrates the importance of robust governance structures, executive sponsorship, cross-disciplinary collaboration, regular feedback of NEAT performance data and major redesign of existing clinical processes, work practices and bed management operations. WHAT ARE THE IMPLICATIONS FOR CLINICIANS AND MANAGERS?: Improving access to emergency care should be regarded as a problem located and resolved both within and without the ED. It requires a whole-of-hospital solution involving interdisciplinary collaboration and significant change in culture and practice relating to inpatient units and their interface with the ED.

Objectives: To compare time metrics associated with a temporary disruption to ED computed tomography (CT) scanner location from adjacent to the ED with direct access from resuscitation rooms, to a location remote to the ED. Methods: A retrospective before and after study was conducted in a public metropolitan ED with over 66 000 presentations annually. Time‐to‐CT metrics, operational time metrics and ED length of stay were extracted and analysed from presentations between October 2020 and January 2021. Results: There were 3031 CT scans during the study period. Overall, the disruption was associated with a significant 27–36 min delay (P < 0.01) in time‐to‐CT start; these delays were also observed in a subset of trauma patients. In a subset of presumed stroke patients, time‐to‐brain perfusion was significantly delayed by up to 10 min (P < 0.01). There was a 14% (P < 0.01) greater demand for operational services and a time imposition of up to 8 min (P < 0.01) to transport patients to or from CT scanning when the CT scanner was located away from the ED. ED length of stay was consistent at all time points. Conclusion: Although rapid, proximate access to CT scanning is often considered desirable in terms of the management of trauma and other time‐critical emergencies, the wider time and resource implications demonstrated in this study suggest a potential broader benefit to co‐located CT scanning in ED. Our experience could be considered in future re‐design of EDs. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to demonstrate through practical application how a system dynamics (SD) patient flow model of an emergency department (ED) can show which levers effectively reduce backlogs to improve access to care. Overcrowded EDs are struggling to meet demand and access targets. In 2016 and 2017, in the UK and Australia, respectively, 15% and 28% of arrivals waited longer than the targeted 4‐hr treatment time. Historically, simulation models that have informed access to emergency care have ignored the wider systems impacts. There is a growing awareness of the value of systems analysis tools for informing interventions and policy. In this study, we constructed a pilot system dynamics patient flow model, where the scope was the ambulatory and ambulance patient arrivals, the ED processes for acute and fast‐track pathways, pathology and radiology services, the ED short‐stay unit, and the Medical Assessment Planning Inpatient Unit. Patients queued to access constrained ED resources (doctors and beds) and diagnostic services (pathology and X‐ray). The model was tested on actual data from five separate historical periods spanning 3 years. The resultant daily pattern of peaks and troughs in patient flow and system delays accurately replicated patterns in actual patient flows, resource use, and the location of delays. "What if" scenario analysis (b) simulated how access would have looked in the sample weeks with different intervention strategies, (b) simulated system limits on the basis of current resources, (c) accurately identified levers that historically have been most effective at minimizing ambulance ramping, and (d) identified when additional staffing would fail to improve flow. [ABSTRACT FROM AUTHOR]

Traditional and current approaches to modelling the impacts of health care interventions have focused on detail complexity and been ceteris paribus dependent and thereby ignored the wider system impacts. In this study, we have demonstrated that system dynamics (SD) offers theoretical and practical advantages over conventional methodologies and the qualitative assessment tools that have informed the business of emergency care. We translate the key findings of qualitative research, existing literature reviews and studies of the use of simulation and economic evaluation models into a value proposition for using SD tools. We conclude that there is growing evidence of a strong value proposition for the use of SD tools to investigate interventions targeting improved emergency care access. SD models can incorporate dynamic and organizational complexity and fill a gap beyond the microscope of the conventional methodologies informing health care. This potential to strengthen health care systems warrants further investigation. [ABSTRACT FROM AUTHOR]

Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED–in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED–in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18 million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care. [ABSTRACT FROM AUTHOR]